We are all different. We all have
different family situations, different jobs, different strengths, and different
weaknesses. Despite all these differences, there are a number of very common emotional
stages that people with a head injury go through. This is based upon my own experience
treating patients, but many investigators note similar findings.

Confusion and Agitation

The first phase that I see people
going through is a confusion/agitation phase. This can last minutes or it can last for
months. I've had people get in a car accident and be somewhat dazed for a few minutes, but
then direct traffic around their car. Others had been brought into the hospital in a coma
requiring intensive medical efforts. When they wake up, they may go through the
confusion/agitation phase. In the hospital setting, this is very difficult for family
members. Someone who is very meek and mild, for example, can be physically aggressive.
They may punch the nurses, or swear and curse at family members. It's very frightening for
family members, and it feels like it is going to last forever. For 99% of the patients
that I've worked with, this confusion/agitation phase goes away. It may take a while, but
people eventually come out of it.

Denial

The next emotional phase that I
see people typically go through is denial. The patient says, "There's nothing
wrong with me." For example, they're in a motor vehicle accident, they're briefly
seen in an emergency room, and they go home. Suddenly, they're having difficulties.
They're forgetting things or burning food. Family members may say, "you seem
different." But the head-injured person says "No, there's nothing wrong
with me." Often the medical system unknowingly supports denial. Many doctors will
say, "Go home, relax for two weeks, and everything will be better." For
some people, things don't get better. They wonder why they're doing some silly things. For
example, why did they put their shoes in the refrigerator? Or why did they put the milk in
the closet? They have these odd events and they keep rationalizing them away. Denial can
be very difficult for both family members and medical staff. For example, the head-injured
person may say, "Yes, I can drive," but family members who have been with
the person know that it would be dangerous. This can stir up huge arguments. The person in
denial says there's nothing wrong, even when directly confronted by family members. When
someone is in denial, you must give consistent feedback that everything is not
"okay." Generally, very direct feedback is necessary. However, some people get
really angry when they're constantly being told "NO". I often find that
distraction, such as changing the topic of conversation, is better than getting into
long-winded or violent arguments. For example, the head-injured person may want to drive
when it's not safe to do so. Instead of arguing, it might be better to say, "Your
doctor has not cleared you to drive" and move on with the conversation.

There are two types of denial.
The first type of denial is an emotional one. Something has happened that is so terrible,
or so frightening that they just don't want to deal with it. The second type of denial
comes from changes to the brain. The brain literally refuses to process certain types of
information. For example, there is one type of injury to the brain where the patient
cannot receive visual information on the left side. Their vision is gone on the entire
left sidebut they don't know it. They may bump into walls, or, if driving a car,
they may run into things. If drawing a picture, they may leave out half the drawing. The
brain doesn't like missing information, so it tends to fill in that information. You may
be thinking that you dont know anyone who has part of their vision missing. Think
again! Did you know that part of your vision has a hole in it? Where the optic nerve comes
through on the eyeball, there are no visual receptors. The brain doesnt like missing
information and "fills in" that little hole. If you close your left eye, hold a
pencil about one foot from the eye (down and to the right), the eraser will just disappear
when you find this small hole. So, now you see how the brain can contribute to
"denial."

Anger and Depression

Denial is a very common problem,
but eventually it breaks down. Head injury problems just don't go away. The same problems
happen over and over and over again. This leads to the next phase, in which the person has
a limited awareness of the head injury, beginning what I call the depression/anger phase.
When you realize you are different and can't do things like you used to, you may become
angry or depressed. In many ways, anger and depression share a lot in common. Some people
think of depression as anger at oneself, a kind of anger turned inward. A lot of people
who are depressed will say to themselves, "I'm a failure. I can't do this. I'm no
good." On the other hand, people who are struggling to deal with the vast changes
produced by a head injury may get angry at people around them. They may see people as not
being supportive of them or not understanding their head injury. Some of this anger may
also be due to the head injury. They'll notice that this anger comes on extremely quickly
and also goes away just as quickly. That's due to the head injury. The sections of the
brain that control those emotions have been injured.

Not all of this anger or
depression is due to physical changes in the brain. Instead, we're talking about an
emotional way of coping with things. Virtually all people who go through a serious illness
or injury will have some anger and depression. If it is a car accident, they may be angry
at the person who ran into them. They may be angry at themselves for getting into an
accident. Sometimes it is justified, such as in a case where a person has been drinking
and driving, resulting in a head injury. Sometimes they unreasonably blame
themselves--"If I had only left my house five minutes later or five minutes
earlier, I wouldn't be in this mess." There was no way of knowing that an
accident would happen. When we have difficulty dealing with overwhelming situations, we
often go back and blame ourselves. That's a very common reaction. Many religious people
become angry at God--Why would God want me to suffer? They may question their
faith, or wonder why God is so vindictive. Just about everybody goes through this cycling
pattern, becoming depressed or angry. This can go back and forth; some people never move
on to the next phase.

Testing Phase

The next phase almost always
follows after a period of recovery and improvement in thinking abilities. When people
eventually realize they are improving, they go through the testing phase. Basically, they
test themselves to see their limits. To some degree, there's a little bit of denial in
this. The person feels, "I'm really close to the way I was, so I'll just act the
way I was. I'll do things as I always did." For example, many people with a head
injury have a fatigue disorder. They know they get tired easily. But during this testing
phase, they "forget" they have a head injury and say, "Well, I've got a
lot of friends visiting this weekend. I'm just going to stay up really late. I'm going to
see if I just can't be the way I used to be." When you overdo and go beyond your
abilities, you may spend the next several days paying for it. Sometimes, people will test
themselves and fail. For example, they previously may have been an A or B student. They
take a class and come out with a C or D, even though they put in twice the effort for that
C. For many people, getting a C is a failure. There's a period of time when the
head-injured person says, "Why can't I be the way I used to?" This a very
painful stage.

Uneasy Acceptance

The next phase is what I call
uneasy acceptance. This is when head-injured people learn where they stand and what their
limits are. They've learned after many failings and many times of paying for it, that they
can only handle a limited number of hours of work or play. They've learned to keep a
consistent schedule and will stick to that schedule. For example, they can work six hours
a day, but realize that 8 hours is too much. They've learned to say, "I have to
deal with this head injury." Does this mean they like it? NO. They're not happy
about it, but they've learned to accept it. Often individuals in this phase begin to use
words like the "old" me and the "new" me. Many of their old friends
are no longer with them, but they've found new friends. They've moved on to new
relationships, maybe even new work, and they've basically said, "People have to
like me for what I am." That's "uneasy acceptance".

Now you will notice that I
haven't talked about the level of injury (or how bad off the person is). I have many
patients who have no scars, no physical problems, and have largely returned to their own
job, yet they're different. Sometimes those people have the greatest difficulty with
acceptance. Often people who "seem fine" have greater emotional problems than
those who have obvious disabilities. These emotional phases really don't correlate with
how physically impaired they are, or whether they return to their own job or not. It
varies with the person.

Factors in Emotional
Adjustment

Some people tend to handle the
stress of a head injury better than others. In general, people who do well emotionally
tend to have a very strong work ethic. They tend to believe that it's important to
contribute to society and to people around them. It's important to help others. They look
outside of themselves to see what they can do to make the world around them better. In my
experience, these people tend to do better. On the other hand, people who are extremely
self-centered and who have poor social relationships before their injury tend not to do
well. One important predictor of how well people do is a sense of humor. I believe that
humor is an essential component to getting better. I like to joke with the people that I
work with, but not in a hostile way or to make fun of them. Sometimes people can make
jokes about themselves; that's a very positive sign. One of my patients told me, "Sometimes
laughing keeps me from crying." Another factor is people's avoidance of drug and
alcohol problems. Some people cope with their personal failures or personal problems
through alcohol or drugs. If you return to alcohol or drugs and don't see the destruction
it causes, you will have a hard time coping with this injury. That doesn't mean that
people who abuse alcohol or drugs are always going to have negative outcomes. The
question is, have those people learned that using alcohol or drugs will make their brain
worse?

Another factor in head injury is
whether or not people freely admit to others that they have a head injury. Many of my
patients at first didn't want anybody to know about their injury. People are afraid that
others might think they are "dumb" or "retarded." But after a while,
these same patients realize that there are a lot of people in this world who have had head
injuries. People who have dealt with a head injury over a long period tend to "reach
out" to those who are just starting the process of recovery. Some of my patients have
gone beyond just talking with someone on a one-to-one basis. Some have even lectured, have
gone to schools and talked about wearing helmets; or talked about drinking and driving.
People who have suffered a head injury somehow move beyond their suffering to help others.

People who go to support groups
often get a lot of positive feeling from being with other head-injured people. They want
to openly talk about their frustrations or fatigue or forgetting things. Those people do
better. On the other hand, people who avoid talking about their accident, avoid telling
people they have a head injury, and avoid being with other head-injured patients tend to
have a poorer adjustment. In every state in the United States, there is a brain injury
association with some type of support group. Dont be afraid to check one out.